Presentation and management of pneumomediastinum in patients with COVID-19 infection

Pneumomediastinum, characterized by the presence of air in the mediastinum, can be primary (spontaneous) or secondary. Although relatively rare and usually benign with an incidence of 1 in 7,000 to 12,000 hospital admissions, some cases can develop hemodynamic instability due to mechanical pressure, reducing venous return and may require emergency surgery. Prior to the COVID-19 pandemic, reports of tension pneumomediastinum were infrequent, and there was no consensus on the best surgical approach to manage this condition. This review considers the diverse presentations, underlying causes, and diagnostic and operative approaches in patients with COVID-19 infection and pneumomediastinum. A systematic search of databases, including PubMed and Scopus, was conducted. Articles were reviewed to identify the risk factors for pneumomediastinum, the hemodynamic consequences, and approaches to management in both COVID-19 and non-COVID-19 cases. In patients with COVID-19 infection, pneumomediastinum represents a risk factor for poor outcomes, especially in patients requiring mechanical ventilation. In patients with tension pneumomediastinum, surgical release of mediastinal air is essential and can use suprasternal incisions, lateral sternal incisions, or sternotomy, all with drains. These patients are also at increased risk for tension pneumothorax and may require surgical chest tubes. Keywords: Pneumomediastinum, COVID-19, hemodynamics, surgical management, clinical challenges